You are in: eMedicine Specialties > Obstetrics and Gynecology > Prolapse and Incontinence Uterine ProlapseArticle Last Updated: Aug 14, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: George Lazarou, MD, FACOG, Assistant Professor, Department of Obstetrics and Gynecology, Women's Health, Director, Urogynecology/Reconstructive Pelvic Surgery, Jack D Weiler Hospital, Albert Einstein College of Medicine; Chief, Urogynecology/Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Bronx-Lebanon Hospital Center George Lazarou is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Urogynecologic Society, and National Association for Continence Coauthor(s): Richard J Scotti, MD, FACOG, FACS, Director of Obstetrics/Gynecology, Montefiore Medical Center, Chief, Urogynecology and Reconstructive Surgery, North Central Bronx Hospital; Associate Professor, Department of Obstetrics/Gynecology, Albert Einstein College of Medicine Editors: Jordan G Pritzker, MD, MBA, FACOG, Assistant Professor of Obstetrics, Gynecology, and Women's Health, Women's Comprehensive Health Center, Albert Einstein College of Medicine; Physician-In-Charge, Dept of Obstetrics and Gynecology, Long Island Jewish Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Assumption Community Hospital; Michel E Rivlin, MD, Associate Professor, Coordinator, Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine Author and Editor Disclosure Synonyms and related keywords: UP, prolapsed uterus, pelvic organ prolapse, POP, urinary incontinence, UI, genitourinary prolapse, procidentia, pelvic relaxation, pelvic floor defects, multiparity, genital atrophy, hypoestrogenism, pelvic tumors, sacral nerve disorders, diabetic neuropathy, obesity, Marfan syndrome, lower urinary tract dysfunction, hydronephrosis, obstructive nephropathy, urinary retention, hysterectomy, sacral colpopexy, sacral uteropexy, sacropexy, hysteropexy, sacrospinous ligament fixation, modified McCall culdoplasty, iliococcygeus fascia suspension, Kegel exercises, pessary, pessaries INTRODUCTIONSection 2 of 11
  The gradual increase in life expectancy in developed countries over the past century has produced an increased demand on the health care system for practitioners conversant with disorders of the elderly population. Pelvic organ prolapse (POP) and urinary incontinence (UI) are common conditions affecting many adult women today. POP is the abnormal descent or herniation of the pelvic organs from their normal attachment sites or their normal position in the pelvis. In this article, the authors discuss the clinical presentation, pathophysiology, evaluation, and management of uterine prolapse (UP). History of the ProcedureUP was first recorded on the Kahun papyri in about 2000 BCE. Hippocrates described numerous nonsurgical treatments for this condition. In 98 CE, Soranus of Rome first described the removal of the prolapsed uterus when it became black. The first successful vaginal hysterectomy for the cure of UP was self-performed by a peasant woman named Faith Raworth, as described by Willouby in 1670. She was so debilitated by UP that she pulled down on the cervix and slashed off the prolapse with a sharp knife. She survived the hemorrhage and continued to live the rest of her life debilitated by UI. From the early 1800s through the turn of the century, other successful surgical approaches were used to treat this condition. ProblemUP is a defect of the apical segment of the vagina and is characterized by eversion of the vagina with attendant descent of the uterus. Patients may present with varying degrees of descent. In the most severe cases, complete procidentia, the uterus protrudes through the genital hiatus. UP is the most troubling type of pelvic relaxation because it is often associated with concomitant defects of the vagina in the anterior, posterior, and lateral compartments. FrequencyThe exact prevalence of POP is difficult to determine. However, it is estimated that the lifetime risk of requiring at least 1 operation to correct incontinence or prolapse is approximately 11%.1 EtiologyPelvic floor defects are created as a result of childbirth and are caused by the stretching and tearing of the endopelvic fascia and the levator muscles and perineal body. Partial pudendal and perineal neuropathies are also associated with labor.2 Impaired nerve transmission to the muscles of the pelvic floor may predispose them to decreased tone, leading to further sagging and stretching. Therefore, multiparous women are at particular risk for UP. Genital atrophy and hypoestrogenism also play important contributory roles in the pathogenesis of prolapse. However, the exact mechanisms are not completely understood. Prolapse may also result from pelvic tumors, sacral nerve disorders, and diabetic neuropathy. Other medical conditions that may result in prolapse are those associated with increases in intra-abdominal pressure (eg, obesity, chronic pulmonary disease, smoking, constipation). Certain rare abnormalities in connective tissue (collagen), such as Marfan disease, have also been linked to genitourinary prolapse.3 A review of the detailed mechanisms that can lead to UP is beyond the scope of this article. However, thorough evaluation and definition of all support defects is of critical importance because most women with UP have multiple defects.4 ClinicalIn a 1999 study of Swedish women aged 20-59 years, Samuelsson and colleagues found that, although signs of POP frequently are observed, the condition seldom causes symptoms.5 Minimal UP generally does not require therapy because the patient is usually asymptomatic. However, uterine descent of the cervix at or through the introitus can become symptomatic. Symptoms of UP may include a sensation of vaginal fullness or pressure, sacral back pain, vaginal spotting from ulceration of the protruding cervix or vagina, coital difficulty, lower abdominal discomfort, and voiding and defecatory difficulties. Typically, the patient feels a bulge in the lower vagina or the cervix protruding through the vaginal introitus. Evaluation Identification of concomitant pelvic defects before surgery facilitates simultaneous repair of other defects and minimizes the chance for recurrence. Optimally, surgeons should plan the most appropriate procedures necessary to correct all defects at the same surgical setting. When a patient presents with complaints of UP, a detailed history and a site-specific assessment of all pelvic floor defects are critical to the evaluation. Patients are often referred for asymptomatic prolapse. Shull's axiom that "the asymptomatic patient cannot be made to feel better by medical or surgical therapy" provides good advice (1993). The gynecologist's responsibility is to address the individual needs and wishes of patients. Assessment of quality of life is also helpful in determining appropriate treatment. A detailed sexual history is crucial, and focused questions or questionnaires should include quality-of-life measures. Voiding difficulties and urinary frequency, urgency, or incontinence are common symptoms associated with POP. If present, these symptoms should be investigated because advanced prolapse may contribute to lower urinary tract dysfunction, including hydronephrosis and obstructive nephropathy. Surgery for the correction of incontinence is less successful in patients with POP.6 Incontinence is discussed elsewhere (see Incontinence, Urinary: Comprehensive Review of Medical and Surgical Aspects, Incontinence, Urinary: Surgical Therapies, and Incontinence, Urinary: Nonsurgical Therapies). Urinary retention is also common for patients with UP because they often have concomitant descent of the anterior vaginal wall. An anatomic kinking of the urethra may cause obstructive voiding and urinary retention. Always determine the postvoid residual urine volume to exclude obstruction as a consequence of urethral kinking or incomplete emptying secondary to poor bladder contractility. Complete preoperative assessment can prevent many postoperative complications. The authors recently reported a series of patients with significant anterior vaginal wall prolapse who exhibited urinary retention. Each patient underwent preoperative prolapse reduction testing using a pessary. This test was found to have high sensitivity, specificity, and positive predictive value for the postoperative cure of urinary retention. In this series, reconstructive pelvic surgery cured most patients with urinary retention problems.7 Note significant medical history (eg, obesity, asthma, long-term steroid use) that may have contributed to prolapse or UI. It may be wise to attempt to correct some of these problems, if possible, before any surgical treatment. Recurrences may be more likely if such conditions are not addressed. A site-specific physical evaluation is essential. Methods for noting pelvic floor relaxation include (1) the Baden halfway system; (2) the International Continence Society (ICS) classification, using the Pelvic Organ Prolapse Quantification (POPQ) system; and (3) the revised New York Classification (NYC) system.8, 9, 10 The authors routinely use the more comprehensive NYC system, which preserves the ordinal staging of the Baden halfway system and may be converted to the POPQ. The authors have recently validated its interobserver reliability.11 In all these systems, stage I is defined as descent of the uterus to any point in the vagina above the hymen; stage II, as descent to the hymen; stage III, as descent beyond the hymen; and stage IV, as total eversion or procidentia. Evaluate the patient in both the lithotomy and standing positions, during relaxation and maximal straining. To perform the evaluation, place a standard double-bladed speculum in the vaginal vault to visually examine the vagina and cervix. The speculum is removed and taken apart, leaving only the posterior blade, which is then replaced into the posterior vagina, allowing visualization of the anterior wall. The monovalve speculum is then everted to view the posterior wall. Note the point of maximal descent of the anterior, lateral, and apical walls in relation to the ischial spines and hymen. Next, place 2 fingers into the vagina such that each finger opposes the ipsilateral vaginal wall, and ask the patient to bear down. After evaluating the lateral vaginal support system, assess the apex (cervix and apical vagina). Repeat the examination with the patient standing and bearing down in order to note the maximum descent of the UP. Next, grade the strength and quality of pelvic floor contraction, asking the patient to tighten the levators around the examining finger. Assess the external genitalia, noting estrogen status, diameter of the introitus, and length of perineal body. Perform a careful bimanual examination and note uterine size, mobility, and adnexa. Lastly, perform a rectal examination, assessing the external sphincter tone and checking for the presence of rectocele or enterocele. When the patient has significant UP, excluding potential incontinence (PI) is imperative. By definition, PI is the development of incontinence only when the prolapse is reduced. This "unmasking" of UI is a result of unkinking the urethra. To test for PI, the bladder is retrograde filled to maximum capacity (at least 300 mL) with sterile water or saline while replacing and elevating the UP digitally or with an appropriately fitted pessary. The patient is then asked to cough. If the patient leaks urine, the authors recommend complete urodynamic testing. If PI is not addressed before reconstructive surgery, up to 30% of patients may become incontinent after even the best of surgical repairs. In patients with PI, reduction of the UP may unmask intrinsic sphincter deficiency.12 Such patients may require treatment for their PI that differs from that for patients with normal-pressure urethras. INDICATIONSSection 3 of 11
The primary management of severe UP is surgical. For patients in whom conservative management has failed, a variety of surgical approaches to correct POP are available. When planning the appropriate approach, the surgeon must consider operative risk, coital activity, and vaginal canal anatomy. The following list illustrates variables that must be considered. Important considerations for nonsurgical or surgical decision making
RELEVANT ANATOMYSection 4 of 11
Knowledge of the anatomy of the pelvis is essential to understanding prolapse. Teleologic reasoning aids in the understanding of POP. The pelvic floor evolved in primates, particularly humans, who as bipeds, spend most of their waking hours in the upright position. As the name suggests, the floor of the pelvis is the lowest boundary on which all the pelvic and abdominal contents rest. The pelvic floor is composed of a sling of several muscle groups (levators) and ligaments (endopelvic fascia) connected at the perimeter to the 360° ovoid bony pelvis. Furthermore, knowledge of the biaxial orientation of the vagina and uterus is critical to understanding the anatomic and functional relationships and to proper surgical restoration of the pelvic supports. In the supine position, the upper vagina is almost horizontal and superior to the levator plate.13 The uterus and apical vagina have 2 principal support systems. Active support is provided by the levator ani; passive support is provided by the condensations of the endopelvic fascia (ie, the uterosacral-cardinal ligament complex, the pubocervical fascia, the rectovaginal septum) and their attachments to the pelvis and pelvic sidewalls through the arcus tendineus fascia pelvis. The levator ani muscles are fused posteriorly to the rectum and attach to the coccyx. The genital hiatus is the perforation on the pelvic floor through which passes the urethra, vagina, and rectum. CONTRAINDICATIONSSection 5 of 11
Contraindications to surgical correction of uterine prolapse are based on the patient's comorbidities and her ability to tolerate surgery. Patients with mild UP do not require surgery because they are usually asymptomatic. WORKUPSection 6 of 11
Imaging StudiesIf the uterus is to be preserved, ultrasonographic imaging is strongly recommended. Diagnostic ProceduresIf the uterus is to be preserved, preoperative endometrial biopsy (and/or ultrasonographic imaging) is strongly recommended. TREATMENTSection 7 of 11
Medical therapyPatients with mild uterine prolapse do not require therapy because they are usually asymptomatic. However, when symptoms occur, many patients initially opt for conservative treatment. In addition, patients who are poor surgical candidates or are strongly disinclined to surgery can be offered pessaries for symptom relief. Topical estrogen is an important adjunct in the conservative management of patients with UP. When operative repair for prolapse of the uterus is chosen, a clear surgical plan must be formulated. The pelvic surgeon should consider surgical risks, coital activity, and normal vaginal anatomy. The correct operation must be tailored to the individual patient (see Indications). Other questions that must be answered include whether the operation is performed abdominally, vaginally, or laparoscopically and whether a hysterectomy should be performed. A hysterectomy is not necessarily a mandatory part of the surgical repair for UP because various types of uterine suspensions can be performed via the abdominal or vaginal route. However, for practical reasons, the uterus is often removed to provide better access to the apical reattachment points, particularly the uterosacral, cardinal, sacrospinous, and anterior sacral ligaments. Conservative treatment Pelvic exercises and pessaries are the current mainstays of nonsurgical management of patients with UP. Although routine Kegel exercises can improve pelvic floor muscle tone and stress UI, no evidence in any prospective, blinded, randomized trials indicates that improvement of pelvic floor muscle tone leads to regression of UP. Vaginal support devices are excellent options for treating patients with UP conservatively, and pessary use has few contraindications aside from acute pelvic inflammatory disease and pain after insertion. Recurrent vaginitis is a relative contraindication and may require removal of the pessary. An important adjunct is application of topical estrogen to the everted vagina, particularly if signs of hypoestrogenism exist. Many different types of pessaries can be used, and pessary fitting is far from an exact science. Trial and error is the rule. Initially, the authors try the two most common types, ie, the ring with support and the donut pessary, depending on concomitant pelvic floor defects. Other types are the inflatable ball, cube, and Gehrung pessaries. The Gellhorn is most often used for patients with significant UP and a large introital diameter who have not obtained relief with other pessaries. The Smith-Hodge and Risser pessaries facilitate retrodisplacement of the uterus and should be used for patients with a well-defined pubic notch and adequate vaginal width. Surgical therapyThe primary management strategy for severe UP is surgical. For patients in whom conservative management has failed, a variety of surgical approaches are available to correct POP. Abdominal approach If an abdominal approach is selected for the correction of UP, the authors' preferred operations are abdominal sacral colpopexy or sacral uteropexy. Both operations allow the upper vagina to regain its normal anatomic axis (sitting upon and parallel to the pelvic floor) by securing the apical vagina or the uterus to the sacrum with sutures through the presacral fascia at the promontory or at S3 if it is strong and free of vessels. The authors' biomechanical anatomic studies have demonstrated that the presacral fascia is strongest at the promontory.14 If the promontory is chosen, the intervening material must be applied loosely so that there is no tension on the vagina during straining and the vagina rests on the levator plate. These abdominal forces can be hypothetically tested intraoperatively by means of gentle downward traction on the vagina and graft material before trimming the material and securing the suture. The abdominal approach generally allows higher fixation in the pelvis and provides durable repair with sufficient vaginal length. Sacropexy procedures use grafts of harvested fascia lata15, abdominal fascia, dura mater, Marlex, Prolene, Gore-Tex, Mersilene16, or cadaveric fascia lata. Grafts are placed from the vaginal cuff, the amputated cervical stump, or the uterine corpus to the presacral fascia. The authors prefer to attach the graft to a large area of both the anterior and posterior vaginal walls, which reduces large mid-to-high cystoceles and rectoceles in many instances. Permanent suture is used, and the graft is peritonealized to prevent any bowel entrapment. As mentioned previously, the authors routinely perform a culdoplasty. This procedure involves obliterating the cul-de-sac by suturing the peritoneal surfaces together, usually incorporating the uterosacral ligaments in the repair. Vaginal approach Most commonly, vaginal surgery is preferred because the patient usually has a shorter recovery time with this approach. In addition, it is selected if a vaginal approach is planned for the correction of incontinence (eg, for placement of a suburethral sling) or when concomitant vaginal reconstruction is indicated. The 3 common vaginal procedures to suspend the prolapsed vaginal apex are sacrospinous ligament fixation, modified McCall culdoplasty, and iliococcygeus fascia suspension. As originally described by Amreich and modified by Richter and Nichols, sacrospinous ligament fixation is usually performed on the patient's right side to avoid the rectosigmoid.17 The vaginal apex is attached, using permanent sutures, to the sacrospinous ligament. A thorough knowledge of pelvic anatomy is critical to avoid complications. Take care to place the sutures 1-2 cm medial to the ischial spine to avoid injury to the pudendal bundle and the inferior gluteal vessels. Place the suture through—rather than around—the ligament. Excellent results have been reported for correcting vaginal vault prolapse using fixation to the sacrospinous ligament. However, in 1992, Shull and colleagues reported a predisposition for recurrence of anterior vaginal wall relaxation after sacrospinous ligament fixation.18 The McCall culdoplasty may be used to correct apical descent or as prophylaxis against future prolapse.19 This procedure uses the uterosacral ligaments, which, if strong, are shortened and reattached to the vaginal cuff after completion of the vaginal hysterectomy. In the authors' opinion, attaching the prolapsed vagina to stretched prolapsed uterosacral ligaments is of little value. The surgeon must be bold enough to grasp the uterosacrals near the sacrum, where they are usually strong and undetached, but careful enough to respect and avoid the neighboring ureters. Intraoperative cystourethroscopy is therefore essential to be sure the ureters have not been ligated or kinked. The iliococcygeus fascia suspension provides effective cuff suspension, since it attaches the apex to the obturator internus fascia and iliococcygeus fascia with less risk of neurovascular damage than does the sacrospinous ligament fixation.20 Alternatively, the authors have described placing the suture through the iliococcygeus and the periosteum at the ischial spine, where it is attached.21 If an enterocele is encountered after removing the uterus, the sac is separated from the vagina. This redundant "hernia sac" is ligated at its neck and excised. Take care to avoid any loops of small bowel, which may also prolapse into the cul-de-sac between the vagina and the rectum. If the enterocele is not adequately repaired, the patient may have recurrence of apical, posterior, or anterior defects, with prolapse of the vagina vault. For patients who cannot undergo long surgical procedures and who are not contemplating sexual activity, obliterative procedures, such as the Le Fort colpocleisis or colpectomy and colpocleisis, are viable options. With the Le Fort colpocleisis, a patch of anterior and posterior vaginal mucosa is removed. The cut edge of the anterior vaginal wall is sewn to its counterpart on the posterior side. As the approximation is continued on each side, the most dependent portion of the mass is progressively inverted. A tight perineorrhaphy is also performed to help support the inverted vagina and prevent recurrence of the prolapse. The authors have described and reported a procedure for denuding the anterior and posterior vaginal mucosa with a dermatome.22 The main problem specific to these obliterative operations is that they limit coital function. Neither corrects an enterocele because they are both extraperitoneal procedures. Also, there is a 25% incidence of postoperative urinary stress incontinence caused by induced fusion of the anterior and posterior vaginal walls and flattening of the posterior urethrovesical angle. In addition, if the uterus is retained, the patient can later bleed from many causes, including carcinoma. Preoperative detailsAlthough the choice of procedure largely depends on the surgeon's preference and experience, also consider factors such as the patient's general health status, degree and type of POP, need for preservation or restoration of coital function, concomitant intrapelvic disease, and desire for preservation of menstrual and reproductive function. When deciding on the type of surgery to correct UP, the pelvic surgeon should remember that UP is the result and not the cause of POP. Therefore, performing a hysterectomy does not correct the apical defect. A careful preoperative evaluation should identify all concomitant defects associated with UP, which should be repaired in order to avoid recurrence of POP. Intraoperative detailsThe challenge to the pelvic surgeon is to recreate normal anatomy while maintaining normal function. Experienced gynecologic surgeons can reevaluate the anatomy intraoperatively, noting the strength and consistency of the various support structures (eg, uterosacral ligaments). If these structures are found to be weak, it may be necessary to use other, stronger reattachment sites, such as the sacrospinous ligament or the presacral fascia, for the correction of the defect. In addition, make every attempt to prevent a recurrence of POP. For example, when performing a retropubic urethropexy for UI, a concomitant colpocleisis may avoid the formation of an enterocele in the future. Postoperative detailsIf a vaginal approach is used, instruct the patient to avoid any exercise or heavy lifting and to refrain from intercourse for 6 weeks after her discharge from the hospital. Subsequent to the 6-week follow-up visit, the patient is instructed to progressively return to her usual daily activities. Stress the need to avoid causes of increased intra-abdominal pressure, such as constipation, weight lifting, and cigarette smoking, for at least 3 months. This facilitates adequate healing and prevents surgical failures. For postmenopausal patients, the authors routinely recommend continuation of estrogen therapy in order to maintain the integrity of pelvic tissues and to maximize surgical success. Follow-upIf conservative treatment is used, depending on symptoms, instruct patients to remove and clean the pessary and/or to douche weekly with a weak vinegar solution to lessen the chances of complications (see Complications). After fitting the patient with the appropriate size and type of pessary, instruct her to return for a follow-up examination at 1 week to assess any inflammatory response, ulceration, or urinary or defecatory problems. If the patient cannot clean and replace the pessary satisfactorily, the provider should clean and replace it every 8-12 weeks. For excellent patient education resources, visit eMedicine's Women's Health Center. Also, see eMedicine's patient education article Prolapsed Uterus. COMPLICATIONSSection 8 of 11
Conservative treatment Pessaries may cause vaginitis, bleeding, ulceration, UI, urinary obstruction with retention, fistula formation, and erosion into the bladder or rectum. Most complications are from a long-forgotten pessary.23 Rarely, carcinoma at the site of contact has been reported.24 Abdominal approach Bleeding is the most serious complication of sacral colpopexy.25 Injuring the presacral venous plexus or the middle sacral artery while operating in the presacral space is possible. Other complications include ureteral injury, graft rejection, and suture pullout (causing recurrence of the prolapse). Erosion of synthetic grafts through the vagina has been reported at a rate of 3% in a series of 370 patients who had undergone sacral colpopexy.26 Vaginal approach Surgical correction of UP has a low complication rate. Reported complications (other than the risks associated with general anesthesia) include pelvic infection, hemorrhage, and injury to the ureters or lower urinary tract with fistula formation, bowel injury, sacral osteomyelitis, and graft rejection. The two most serious complications from sacrospinous ligament fixation are hemorrhage and nerve injury from the pudendal neurovascular bundle. Despite the reported long-term success rates after correction of UP27, surgical failure does occur. For patients who have recurrent POP, a careful evaluation is warranted in order to determine the cause of failure. Most surgical failures are probably related to surgical technique or inaccurate preoperative diagnosis of other concomitant defects. OUTCOME AND PROGNOSISSection 9 of 11
For the first time in history, large numbers of women are living long enough to develop pelvic floor disorders. UP is one of the more common pelvic floor defects and is a challenge to the practicing gynecologist and reconstructive pelvic surgeon. A complete pelvic examination, with particular attention to pelvic support defects, is vital to accurate diagnosis and treatment. Close communication with the patient, her family, and her primary care physician is essential for optimal understanding, informed consent, and management. Offer conservative treatments as the first option, and always try them before any surgical endeavor. Educating the patient and her family strengthens the doctor-patient relationship and improves compliance. When a surgical intervention is undertaken, the primary goals are to restore anatomy and to maintain normal function. Preoperatively, a thorough assessment of all risks or possible complications and a complete discussion of alternatives with the patient are key elements in the decision-making process. Age alone should not be a factor in the decision; rather, the patient's baseline function is an important guideline to selecting the treatment that will provide the best quality of life. FUTURE AND CONTROVERSIESSection 10 of 11
Abdominal approach When operating on patients with UP, rationales for performing a concomitant hysterectomy include the long-term success of the surgery (which can theoretically be affected by the prolapsed uterus) and removal of a nonfunctioning organ in postmenopausal women. In addition, any uterine or cervical pathology (eg, large fibroid uterus, endometriosis, pelvic inflammatory disease, endometrial hyperplasia, carcinoma) may require removal of the uterus. No evidence indicates that hysterectomy has any effect on long-term success of sacropexy. Furthermore, the efficacy of incontinence surgery, with complete pelvic floor reconstruction, is not affected by whether a hysterectomy is performed.28 The authors advocate hysteropexy when the uterus is normal and the patient desires future childbearing. The duration of surgery is shorter, and the uterus itself can serve as the bridge between the vagina and sacrum, thus avoiding the use of autologous, heterologous, or synthetic materials. If the uterus is too bulky, hysterectomy is preferable. The decision may be made intraoperatively, and the patient should be appropriately counseled. If the uterus is to be preserved, preoperative endometrial biopsy and/or ultrasound imaging is strongly recommended. Vaginal approach With a trend toward minimally invasive endoscopic surgery, procedures have been developed to accomplish repair of pelvic defects via laparoscopic approaches. Although results in short-term subjective reports are excellent, objective data are lacking. Few clinical trials have compared laparoscopic procedures with conventional open procedures. Consequently, the exact benefits and risks of operative laparoscopy for patients with pelvic floor defects are not known. The attractive advantages of laparoscopic vault suspension are shorter hospitalizations, better cosmetic results, less morbidity, and shorter postoperative recovery periods. Any advanced laparoscopic reconstructive pelvic surgery requires good operative skills and determination on the part of the surgeon. Most experts agree that the learning curve is usually steep, and complications are more likely to occur in early experiences. A review of techniques for endoscopic repair of UP is beyond the scope of this article, but the goal of any laparoscopic approach is to perform the abdominal procedures through the laparoscope. Before any definitive recommendations are made, prospective randomized trials comparing laparoscopic approaches to open procedures are desirable. Nonetheless, many excellent surgeons have reported excellent results with laparoscopic Burch, paravaginal repair, and sacral colpopexy. REFERENCESSection 11 of 11
Article Last Updated: Aug 14, 2007 |
